ASBESTOS QUESTIONNAIRE

Personal details 

Your full name: 

Your current address:

Your address(es) when you were exposed to asbestos dust.

Tel No: 

Fax No: 

E-mail: 

Date of Birth: 

Nat. Insurance No: 

Marital status: 

Occupational exposure to asbestos fibres

Are or were you employed or self-employed when exposed to asbestos dust?

Years of employment/self-employment during which you were exposed you to asbestos dust:

Names and addresses of all employers throughout your career indicating those which exposed you to asbestos dust.  Please provide any changes of name (if any):

Have you kept any contract of employment or wage slips?  If so please retain and provide us with a copy.

Types of occupation within working environment giving rise to inhalation of airborne asbestos dust/fibres.

Exposure to e.g. airborne asbestos dust (how exposed, when, and for how long and by which employer).

Details of any significant breaks in employment/working history.

Describe any training or instructions given by your employer/contractor and any preventative or protective methods or equipment adopted by the employer to prevent the escape  of airborne asbestos dust.

Were you provided with a face-mask/respiratory  equipment/ breathing apparatus?  If so, do you remember the type?  Were you trained in how to use it?  When was it supplied?

Were you provided with any protective clothing?  If so, give details.

Were any facilities provided for the cleaning and storage of protective clothing/equipment?

Was there any exhaust ventilation equipment provided?

Was any vacuum cleaning equipment used?

The system of working when exposed to airborne asbestos dust.

hours

Your estimation of your periods of exposure to airborne asbestos dust per day/month/year.

Describe the conditions you worked in.

Do you have any fellow workers details [e.g. names, addresses, tel. nos] who may be able to supply confirmatory evidence or who may also be suffering from asbestos?

Non-occupational exposure

Were you exposed to airborne asbestos fibres in any activity apart from your work/employment.

Medical details

Your G.P.’s name and address:

Names and addresses of all hospitals attended/name of department and consultant relating to asbestos disease.

Date when you first noted symptoms e.g. breathlessness and when they were reported to your employer or your doctor.

Date you were diagnosed by a doctor with any of the following:

pleural plaques

pleural thickening

asbestosis

asbestos related lung cancer

mesothelioma

Describe your current symptoms

Have you ever smoked?  If so please provide details (how many per day?) and state over what period of time.  If you have given up please state when. 

Do you have any insurance policies (building, contents, motor, credit cards) which provide a legal expenses fund or stand alone legal expenses insurance?  Please check and provide details.

Are you now or were you when you were exposed to asbestos a member of any Trade Union organisation?  If so, please provide details.

Please return by

(1) email to: lawyers@humphreys.co.uk